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Treatment options for squamous cell vulvar cancer by stage

The stage of a vulvar cancer is the most important factor in choosing treatment. However, other factors that affect this decision include the exact location of the cancer on the vulva, the type of cancer, your age, and your overall health.

Stage 0 (carcinoma in situ)

Treatment options for carcinoma in situ and for less advanced pre-cancerous changes (vulvar intraepithelial neoplasia, or VIN) are the same. If left untreated, nearly all will progress to invasive vulvar cancer. Surgery, such as laser surgery, wide local excision, or a skinning vulvectomy may be used, depending on the size and location of the cancer. A topical therapy such as fluorouracil (5-FU) ointment or imiquimod cream may be applied to the abnormal areas. Even if treated, stage 0 cancers may recur (come back) or new stage 0 cancers may form on other areas of the vulva, so good follow-up is important. The 5-year survival rate is nearly 100%, similar to pre-invasive skin cancers in other body sites.

Stage I

Treatment options depend on the size and depth of the cancer and whether the patient also has VIN. If the depth of invasion is 1 mm or less (stage IA) and there are no other areas of cancer or VIN, the cancer is surgically removed along with a 1 cm (less than half an inch) margin of the normal tissue around it.

Another option rarely used for cancers that are larger and quite extensive is a complete radical vulvectomy and removal of the groin lymph nodes.

If the lymph nodes are not removed because the patient is not healthy enough to withstand the surgery, radiation therapy may be given to the groin areas. If the lymph nodes are enlarged, a needle biopsy may be done before treatment to see if the nodes contain cancer cells.

Patients who are not healthy enough to have any surgery may be treated with radiation therapy alone.

Stage II

Stage II cancers have spread to structures near the vulva, such as the anus, the lower third of the vagina, and/or the lower third of the urethra. One option for treatment is partial radical vulvectomy (removal of the tumor, nearby parts of the vulva, and other tissues containing cancer). Surgery may also include removal of the lymph nodes in the groin on both sides of the body (or sentinel node biopsies). Radiation therapy to the area of surgery may be needed if cancer cells are at or near the margins (edges of the tissue removed by surgery).

For women who are too sick or weak from other medical problems to have surgery, radiation (with or without chemotherapy) may be used as the main treatment.

Stage III

Stage III cancers have spread to nearby lymph nodes. Treatment may include surgery to remove the cancer (either a radical wide local incision or partial or complete radical vulvectomy) and lymph nodes in the groin. This may be followed by radiation therapy. Sometimes chemotherapy (chemo) with 5-FU or cisplatin (sometimes with mitomycin) is given along with the radiation to help it work better.

These cancers may also be treated with radiation (with or without chemo) first, followed by surgery to remove any remaining cancer. This is often done to try to preserve normal structures such as the vagina, urethra and anus.

Radiation and chemo (without surgery) may be used as the main treatment for patients who cannot have surgery due to underlying medical problems.

Stage IVA

These cancers have spread more extensively to organs and tissues in the pelvis, such as the rectum (above the anus), the bladder, the pelvic bone, the upper part of the vagina, and the upper part of the urethra. When treated with surgery, the goal is to remove as much of the cancer as possible. The extent of the surgery beyond a radical vulvectomy depends on what organs contain cancer cells. Pelvic exenteration is an option, although it is used rarely. This operation includes vulvectomy and removal of the pelvic lymph nodes plus removal of some of the following: the lower colon, rectum, bladder, uterus, cervix, and vagina.

The standard approach is to combine surgery, radiation, and chemo. Radiation therapy may be done before or after surgery. Chemo may also be given before surgery. Radiation and possibly chemo can also be given to women who cannot have surgery because of prior medical problems.

Stage IVA also includes T1 and T2 tumors with less severe nearby spread but extensive spread to nearby lymph nodes that has caused the lymph nodes to become fixed (stuck to the underlying tissue) or ulcerated (become open sores). These cancers are often treated with radical vulvectomy and removal of the groin lymph nodes. Radiation (often with chemo) may be given either before or after surgery.

Stage IVB

These cancers have spread to lymph nodes in the pelvis or to organs and tissues outside the pelvis (like the lungs or liver). Surgery is not expected to cure these cancers, but may be helpful in relieving symptoms of bowel or bladder blockages. Radiation may also be helpful in shrinking the cancer and improving symptoms. Chemo may also be an option, as is enrolling in a clinical trial.

Recurrent vulvar cancer

When cancer comes back after treatment, it is called recurrent cancer. Treatment options will depend on how soon the cancer comes back and whether the recurrence is local (in the vulva), regional (in nearby lymph nodes), or distant (has spread to organs such as the lungs or bones).

If the recurrence is local, it may still be possible to remove the cancer by surgery or by using combinations of chemo, radiation therapy, and surgery. Vulvar cancer that comes back locally more than 2 years after the initial treatment has a better prognosis (outlook) than cancers that recur sooner.

When the cancer has grown too large or spread too far to be surgically removed (is unresectable), chemo and/or radiation therapy may be used to help relieve symptoms such as pain caused by the cancer, or to shrink the tumor so that surgery may become an option. If treatment is given only to relieve pain or bleeding, it is called palliative (symptom relief) therapy.

It's very important to understand that palliative treatment is not expected to cure a cancer. Women with advanced vulvar cancer are encouraged to enter a clinical trial where they may receive new forms of therapy that may be helpful but are as yet unproven.